Pennsylvania's Public School Code requires a comprehensive health appraisal at school entry, in grade 6 and in grade 11, and H511.336 is the Department of Health's form for recording it whether the exam happens at school or in a private office. The family fills in a health history before the visit, and the examiner documents the physical exam, chronic conditions and immunizations. The school keeps the form in the student's health record.
The parent, guardian or emancipated student completes page 1 (Student History) before the visit and signs a consent for the school nurse and providers to exchange information. The examiner, an MD, DO, PA-C or CRNP, completes page 2 (Physical Exam) and page 3 (Immunization History); page 4 holds comments from anyone.
Before the visit, the family lists all prescription and over-the-counter medicines and supplements, and allergies to medicines, pollens, food or stinging insects with the reaction. Yes/No questions then cover general health, head/neck/spine (including concussion), heart and lungs (exercise symptoms, prior heart tests), bone/joint, skin (including MRSA), genitourinary, menstrual history and dental care, including the name of the student's dentist and time since the last dental visit. Families circle any question they do not know the answer to.
Questions 34 to 41 ask about learning disabilities or ADD/ADHD, bullying, grief or trauma, behavior changes, mood, energy, weight concerns and tobacco, alcohol or drug use. Questions 42 to 45 cover family history of blood, lung, kidney, seizure and heart conditions, unexplained fainting or seizures, and sudden death before age 50. Question 46 points concerns to page 4. The parent, guardian or emancipated student signs to certify the answers and consent to information exchange.
Check whether the student's health history on page 1 was reviewed before the exam, then check the grade the exam is for: K/1, 6, 11 or other. Record height in inches, weight in pounds, BMI, BMI-for-age percentile, pulse and blood pressure. These measurement rows open the exam grid, above the body systems, and the student's name goes on the line at the top of the page.
For each system mark normal, abnormal or defer: hair/scalp, skin, eyes/vision (with a corrected box), ears/hearing, nose and throat, teeth and gingiva, lymph glands, heart, lungs, abdomen, genitourinary, neuromuscular system, extremities, spine (scoliosis) and other. Abnormal findings, recommendations and referrals go in the wide column. If a tuberculin test was done, record the date applied, date read and result or follow-up.
List medical conditions or chronic diseases that require medication, restrict activity or may affect education, using page 4 for more space. Note whether a parent or guardian was present and whether the exam was done at the personal health care provider's office or at school, with the date of exam. Print your name, office address and phone, sign, and check MD, DO, PAC or CRNP.
Photocopy the immunization history from the record or enter vaccine type and date for each dose: DTaP/DTP/DT, Tdap/Td, polio (OPV or IPV), hepatitis B, MMR (with date of physician-diagnosed mumps), varicella vaccine or disease, serology, MCV4, HPV, influenza, Hib, PCV, hepatitis A, rotavirus and others. Medical exemptions take a date issued, reason and date rescinded; religious or philosophical exemptions are requested by the parent in writing to the school.
Page 4 is open space for anyone completing the form. Families write questions or concerns flagged in question 46 here, and the examiner can continue the list of medical conditions or chronic diseases from page 2. Like pages 2 and 3, page 4 has its own student name line at the top.
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Private or School Physical Examination of School Age Student
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The examiner signs page 2 and checks MD, DO, PAC or CRNP. The Department of Health says the exam may be done by the student's primary care provider (MD, DO, CRNP or PA) or by the school's provider, and the form records whether it took place at a personal health care provider's office or at school.
The Department of Health says the physical must be completed within 4 months before the start of the school year. A 2000 letter from the Secretary of Health encouraged schools to request extending this to 1 year, and the Department of Education treats the school year as beginning July 1. Check whether the student's school has that modification.
Yes. The Department of Health posts the 2012 Physical Examination Form in both English and Spanish on its school health physical exams page. The family's history on page 1 can be completed in either version, and the provider pages follow the same layout.
Yes. Page 3 tells health care providers to photocopy the immunization history from the student's record or insert the information in the table. If you attach a copy, still record any medical exemption with its date issued and reason in the exemption lines at the top of the page.